Get Up and Go Syndrome Issues

Hi, Everyone.

I've had Type 1 for 28.5 years now. This past summer, my doc told me that the diabetic community has finally termed a "new" syndrome...it's not really new, I've been complaining about this to my doc now for a few years. They call it the "Get Up and Go" Syndrome. Here's what happens:

I wear an insulin pump (pumper for 18 years). Recently got back to using a CGM. Insurance was a pain in my butt for a while, so I discontinued use (expensive if I gotta pay outta my pocket). Anyways...

First, I fall victim to the Dawn Effect Syndrome in the early morning. This is due to my body releasing massive amounts of hormones usually in the range of 4 to 6 a.m. for me. This is a natural phenomenon; a normal person's body does this to elevate glucose slightly (insulin is less effective in this time period) so that the body has a higher supply of energy when it wakes up. OK...so I increased my basal rate somewhat to account for this successfully. Now, here is where I get the crap beat out of me...

I usually wake up around 7 a.m. during the week, and around 8 or 8:30 a.m. on the weekends. I can see that at typically around this time period, my glucose levels start to rise a bit further even though the Dawn Effect Syndrome is subsiding. I go sit and think about life in the bathroom, and my BG begins to rise. I sometimes have to take insulin (sometimes as much as a 4-unit bolus) just to account for going #2. I then eat breakfast. Usually turns out to be a HUGE mistake for me, as my BG blasts off like a rocket into outer space. I am virtually insulin-resistant until 10:30-11 a.m., at which time a switch flips in my body and the insulin fully kicks into gear. The unfortunate problem is that by that point in time, I've already been insulin stacking in a desperate attempt to get my BG down from the 300's (a person can get REALLY irritated when sitting this high for a few hours). Anywhere from 10-15 units of active insulin on board when the switch flips, and it's time to brace for impact with fruit, juice, granola bars, etc. (I don't even bother with glucose tablets) as my BG comes crashing down. I recently have been having some success by having my basal rate up to 2.2 units/hour starting at 6:30 and going through 10:30 a.m. My insulin:carb ratio is insane for breakfast; is currently 1:3 or 1:4, whereas it's usually about 1:10 for the rest of the day. My mornings are not consistent on a day-to-day basis, though, and it makes me terrified of even eating breakfast (I can deal with the bathroom scenario). I do not eat a lot of fat for meals. I do eat a fair amount of protein, which I take care of with square wave boluses (my liver likes to convert protein into sugar via gluconeogenesis when protein intake is high), and my carb intake is quite reasonable with fiber and incorporating the use of some low-glycemic index foods.

Anyone else go through this? If so, what do you do to keep your BG in check? I'm pushing myself to exercise more (at least 30 min vigorously 3-4 days/week) which is helping, but I don't exercise until later in the day. Maybe I should force myself to get up early and exercise instead? When I manage to exercise on a routine basis, I tend to need a lot less insulin throughout the rest of the day (can be plagued with low BGs), but my mornings are a disaster more frequently than I'd like them to be.

my basals are also different at different times during the day & night
12 am 0.2
4am 0.4
6am 0.5
10am 0.4
9.pm o.3
plus at breakfast i take .5 more bolus to cover breakfast

Have you tried eating a carb free breakfast (eggs,cheese, etc? Or not even eating until 10:30 am? We are all different, and need to try different approaches, until success...

hello todd! i love your candid post!

i USUALLY dont have problems with dp, but SOMETIMES i wake up high the week before my period. i also dread the eating breakfast thing when that happens. i change my i:c ratio to no avail. it wants to be high and makes sure that 2 hours later im still at 190.

i was recently on holiday at my moms house and changed my breakfast routine. i used to eat about 25 carbs for breakfast and then take my dog for a walk for about an hour, no insulin. i am kind of LADA-ing, or am very insulin sensitive, so the long walk would bring me back down to post prandial targets, under 140, for me. if i didnt go anywhere, then id have to shoot a unit.

at my ma´s house, i had to wait for her to have her 18 cups of coffee and do whatever she had to do before we went to the gym. so because of this waiting around i didnt want to eat ANY carbs and then be high for ages before she decided she was ready to go. so i started eating 2 scrambled eggs and a couple of handfuls of almonds with my coffee and half and half. this has been an amazing blood sugar stabalizing discovery for me! i wont go higher than about 150, can exercise for an hour and a half (!!!!) without going high or low! running, boot camp class, astanga yoga, anything i want to do.

maybe try some kind of very fatty brekkie? i would try exercising in the morning and would also try tweaking your basal, as shoshana suggested.

Ditto on this, My breakfast would be eggs or cheese. Maybe a morning walk/exercise would help. Finally, if nothing else works, you might try taking a non-ER metformin right before bed, so it kicks in during the morning.

For my son I have the basal rates set to cover the dawn phenomenon, but since the basal rates seem to effect BS two hours later, I bring the basals back down two hours before his insulin resistance goes away. I also dose his breakfast 20-25 minutes prior to eating.

My son is only nine so the insulin amounts are smaller. His basal is set as:
12:00a -.650
2:30a - .600
5:30a - .775 (dawn phenomenon)
6:30a - .600
5:30p - .650
10:00p - .775 (growth hormones cause a high at this time)

Todd - You've already discovered that you are very insulin resistant in the morning (I:C 1:3-4 instead of 1:10 rest of day). You didn't mention about your actual carb intake for your typical breakfast.

You say you don't eat a lot of fat for meals. Why? If carbs in the a.m. are the trigger to your high BGs, why not experiment with two eggs any style (I like scrambled with 2 ounces of heavy cream.) and some breakfast meat like ham, bacon, or sausage? With a low carb intake for breakfast, you may need to dose some insulin in a square wave for a few hours to metabolize the protein and fat.My square wave (extended bolus is usually 2-4 hours at about 1.0-1.2 units per hour. Your needs may vary, just experiment.

You seem very aware of what the problem is since it's dogged you for awhile. Just do the experiment and record the results. Fat is not to be feared! It's high fat combined with high carbs that spells trouble for heart health. I'm aware what I'm saying is controversial but just give it a try and see how your BG responds. Check out the Low Carb Dietitian for more info on this way of eating.

Wow! I look at your regimen, and I'm no where close to that.

12 am 1.5 U/H
4:30 a.m 1.7 U/H
6:30 am 2.2 U/H
10:30 am 1.7 U/H
4 pm 1.6 U/H
8:30 pm 1.8 U/H

Thank you to all for sharing your thoughts. I've been doing experiments on myself for a while now. I just wish that I could have better consistency from morning-to-morning with respect to how my body is responding. For example, I could eat the same thing for a few days in a row and have a different response to insulin on a daily basis (even with a fresh catheter implanted into a site that is not hardened with scar tissue). Makes it tough. When my BG soars high (>250), I also need to double the amount of insulin for correction purposes. During the day, it's usually 1 U lowers BG by 60. In the morning, it's rather unforgiving (maybe 1 U lowers only about 10-30, depending on how high my BG gets).

Today was a good day for me! Went to bed at 12:30 a.m. with BG of 130 mg/dL and woke at 8:30 with BG of 75 mg/dL. All I had for breakfast was a Dole Acai/Blueberry fruit juice bar containing 22 g of carbs (21 g sugar). Didn't really satisfy my hunger, though. Instead of mixing in protein and fat as additional variables, I only chose to look at base carbs with a simple test. Took 5 units of insulin. BG rose to only 119 within 30 min, then plateau. I had a couple cups of coffee with fat-free creamer, and I'm still hanging out at this level for last few hours with basal rate alone (listed in reply to shoshawna27).

I've noticed in the past that when I incorporate proteins and fats, these are the culprits that give me problems. I need to work on dual wave bolus; immediate action for the sugars with steep insulin:carb ratio, and about 1.5 U/H square wave for 2 hrs to cover the fat/protein on top of my basal. I typically eat around 40-60 g of carbs for breakfast, 20-30 g of protein, and maybe around 10 g of fat (good fat = unsaturated and omega-3 and omega-6). Greek yogurt with freshly-added blueberries is my favorite along with a high fiber granola bar (I really like KIND bars), and glass of milk. Will sometimes have piece of whole wheat toast with butter or jam too. I love eggs, but tend to eat them later in the day since they elevate my BG quickly in the morning. I've also found that bananas (as much as I love them) are not my friend for breakfast...I have to eat these later in the day too. Coffee (maybe two 8-oz cups) is part of my mornings; if I use a heavy creamer containing fat, my BG rises from this too. I'll get this figured out, just gotta know my limitations better now as I will be turning 40 in January. I'm sure my body is starting to enter a new phase in life, and I can't keep thinking that it will respond the same way that it used to when I was younger.

Thank you for the tip! I responded below with a general comment to my discussion post. I'm new to this site, and folks will find that I tend to be rather candid/open when discussing issues. I put a blog post out yesterday to provide my background info. :)

YES, YES...AND YES! I have found, at least on MDI, i'm only able to eat a frickin egg in the morning and coffee. I too just climb and climb. I'm insulin sensitive, considering, and usually have to do about at 1:5 in the AM too (most of that isn't for carbs, it's just to counter-attack the natural rise of BG's), they just climb and climb until about 11AM. OMG, same as you. A ton of insulin in the morning. Like you, it's not 'always consistent' in the AM...sometimes I can get BG's to not move, sometimes by the time I'm leaving for work and maybe walk over to SBucks for some black java, my CGM is screaming, telling me I'm dropping. I hate the mornings and middle of the night the most. UGH! I have a problem with proteins too sometimes...I'm not so sure it's that, I think it's just incorrect basal or something. IDK...when i tried to restart pump on Thursday, by 9AM without eating anything my BG's were already hitting close to 200. I thought it was maybe the 'coffee' for me too but sometimes I can drink it and it does nothing (depending on the 'time of morning') so I don't think it's coffee with or w/out cream, it's just blood sugars rising.

Thanks for posting this, for adding your humor, too. :)

and same things for me too, in terms of ISF, if I wake up high in middle of the night it's like I'm injecting water, other times of the day my ISF becomes very sensitive.

You are most certainly welcome, Sarah, and thank you for sharing your thoughts! My doc has told me that this doesn't happen to all that many diabetics, but it's nice to know that you and I seem to be "in the same boat" regarding this matter. Please do stay in touch. We can help each other try to figure this out. :)

absolutely! It's your AM BG struggles (mine too) which is why I want to start the pump, hoping to get more stable with overnight and mornings. You keep us posted too. you have much more experience and knowledge, I'm certain, than I do. My CDE keeps telling me to eat MORE in the morning, I'm like..."AH, OK...nothin' like spiking high in the morning to start the day with a probable, possible drop to hell a few hours later", ha!

Thanks! I told my doc that it's never been this bad over the last 18 yrs of pumping, and it gets to the point of actually making me scared to eat anything in the morning. My doc wants me to eat breakfast (which I know is one of the most important meals of the day), but when I gotta deal with a massive roller coaster ride, it doesn't make me feel very good about eating anything because my body is beating itself up on its own without any food being a contributing factor (just makes it worse on some days). Stay strong (and patient)! The pump should help you out with the overnight issues (I got this figured out for my body), so I'm just having issues with mornings now. :)

I had the same effect, but not NEARLY as bad. I usually start the day with a 2 unit bolus, because my sugar is rising at that point (Thinking about life in the bathroom)... Breakfast, while not great for me, doesn't turn into that much of a mess... My IC ratio for 5-9AM is 1:12, where for the rest of the day it's 1:17, and my basal bumps up to .9U/hr at 4:30, and stays there through 9:30, and then is back down to .85. So while there is some increased resistance there, it's not nearly as bad as yours.

I'm pumping too. As a T2, my insulin quantities are quite a bit more insane than yours.

I have the same problem as you, and I make it worse with late night binging every once in awhile. No matter have "well" I balance this snacking with boluses, the next morning is guaranteed to be a BG battle.

So, here's the strategy I use that has worked out well for me. First, I set my basal at the "normal" background rate during the dawn/morning craziness. Then, bolused, bolused, bolused, to get the BG in line. I kept doing this for a week, keeping good records, including when I rebounded at the tail end and went hypo -- important to also record what your IOB is when this happens.

Then, with all that data in hand, I was able to graph the insulin requirements by hour, on average, between 4am and 10am. Using this information, I created a segmented basal program to deliver this quantity of insulin in the same time period.

I have a second basal program with higher values that I saved as "Midnight Pig" for those times I give in to worst impulses.

Finally, I set my CGM to alarm low @ 100 instead of 70, so I can catch it on the way down, and if that hits before the end of the basal program I'll switch the higher basal off, eat a handful of skittles, and I almost always good.

With this strategy I stay under 140 during that tough period of the day. Most of the time I'm even able to stay in the 100-110 range, after the initial rise up from 80-85 @ 4am.

It all sounds like a lot of work, but once you have the basals dialed in, it's really nothing more than messing with your CGM low setting 2x a day, which is trivial.

Hope this helps!

One thing that's fascinating to me in this discussion is the highly varying IR among you T1's... As a T2, my IC is 1:4 most of the day, 1:3 during those morning hours. A 33% increase in resistance.

Going from 1:10 to 1:3 is a 233% increase in resistance. 1:10 -> 1:5 is a 100% increase in resistance.

So from this little bit of anecdotal information a first-cut interpretation is that T1's have a lot more volatility in insulin sensitivity. I never knew this!

Thank you for breaking your strategy down in detail! I will experiment further. I too can have a compulsion to eat some food late. Usually, if I can refrain from eating a lot of fat after 8 pm (and focus on low carb food, small quantity of protein, etc.), then I'm in good shape. This has helped me out a lot during the night time hours. It's just those darn mornings that get to me. Thanks again! :)

I think it may have something to do with the fact that T1's don't produce any insulin. We have to supply it directly to our bodies for just about anything we eat. [I think I can safely say that we don't need it for water consumption... ;) ] T2's tend to still produce some insulin within the body...it's just not as effective as it once was, or the production level is not as great as it once was. Since T2's are still able to use some of their own insulin, I think this leads to less chances for volatility in insulin sensitivity. Just a guess on a my part, though. :)